I had Roux en Y Gastric Bypass done the middle of November.  Prior to the surgery, I called my insurer, Champva, and was told that the bariatric center was also calling to verify coverage eligibility.When I called,  I was told that the surgery was a covered benefit if deemed medically necessary and that there were no comorbidities needed if the BMI was over 40 (mine was). The insurance verifier at the bariatric center then called and told me that the surgery was a covered benefit and I appeared to meet all the critera so I could move forward in the process. After I completed all my nut visits and saw the surgeon, the paperwork was to be submitted to the insurance company. My doctor's office called a week later and told me that Champva does not give pre-authorization and as such I would need to sign a paper saying that if they did not cover the procedure, I would be responsible.  They also told me that it was a formality and they saw no reason why it wouldn't be covered as I met all the necessary critera.  About a month ago I recieved a letter  from Champva to the hospital and myself, saying they had denied the hospital bill and asked that it be resubmitted with the history & physical and operating reports.  I haven't heard anything further, have never heard anything from the hosptial at all.  Then last week I got an EOB saying that the doctor's charges were denied as not a covered benefit.  I called Champva and after 30 minutes of them trying to figure out why it was denied when they thought it should be covered, they finally came back and said that it was denied because it was billed as code number 43645 and that is not a covered service, but I should check and see if perhaps it was a typo because 43644 is a covered benefit. I called the Dr.s office and they said, no it was not a mistake, it was billed as such because I have a limb greater than 150, making it a different procedure code.  They also kept saying that they didn't understand why the were saying it wasn't covered because Medicare pays for both and Champva normally pays whatever Medicare pays. I was never informed that the coverage was limited to a distal procedure and the doctor's office doesn't understand why they won't pay.  Now I am stuck with a $20,000 doctor bill and if they will not pay for that, then they will most likely not pay the hospital portion either, which is an additional $36,000!  Is there anything I should know that could help me? Is there anything I can do?  Appeal?  I am overwhelmed by this and I feel that somehow someone dropped the ball.  I don't understand if there were limitations, why neither the bariatric center or myself were informed of them.  Can anyone give me some advice on what to do next?

Good Morning....

I have BCBSM, my VSG surgery was May 14, 2009.  I was told everything was covered, in January 2010 received an EOB saying I owed money, called the doctors office, was told not to worry about it, so I didn't....  just last week, Feb. 2011 received a statement from doctor saying I owe $2500.  What is the appeal process with BCBSM, is it too late?  Time limits, etc?

Thank you!

   Just wondering how long they take to get back to the Dr's office.  The request for my revision should have been faxed in Friday but it will be done tomorrow.  Naturally I want my answer yesterday.  Thanks for any insight.

Hello all. I have a question about how to meet my high deductible. As I mentioned in an earlier post, I have a policy through BCBS of nc, and my deductible is 10k. They will not pay for ANY services until i meet this extreme amount, and I haven't done any of my pre-op tests yet. My question is this: how can I meet my deductible if they won't pay for anything? I mean, do I show my insurance card when i get each test done even though I know that they're not going to cover it, and let bcbs bill me, or will i still be required to pay upfront? Any insight will be appreciated.

I was self pay and here in Charleston, SC the Medical University wanted almost 28k stating that was inclusive but it didn't include the pre-approval appointments which would have run around 500.00.  I couldn't afford to have it there so I went to overseas to India.  With airfare, procedure, visa and 4 nights in a really nice hotel my cost was a little under 13k almost two years ago (surgery was on 4/1/09).  I made arrangements with my Internist to do follow-up care.  His only question was where I was going overseas and when I told him India he said fine.  I asked if he would have said yes if I told him I was going to Mexico and he said he wouldn't have done my follow-up care if that was the case.

My experience in India was really good.  My Internist was completely blown away by how extensive their pre-op testing was (said it was better than MUSC would have done).  While the hospital wasn't as 'pretty' as the ones here, it was spotless and the nursing care was almost too helpful.  The plane ride home was a little tough but not horrible.  All in all, I'm really glad I choose this option.  I haven't had any complications and I'm 3lbs from being half my size (302lbs at time of surgery).  I had my surgery at Wochart Hospital in Mumbai but I think they were bought out by the Apollo chain sometime last year.